Depersonalization disorder may be related to glutamate receptor activation imbalance.

Low-dose ketamine administration mimics, both clinically and on gross neuroimaging, depersonalization disorder. The perceptual effects of ketamine may be due to secondary stimulation of glutamate release and lamotrigine, possibly by inhibited glutamate release, may reduce some of ketamine's so-called dissociative effects. However, lamotrigine does not seem to be useful in the treatment of depersonalization disorder. Glutamate release in prefrontal cortex is increased by subanaesthetic doses of ketamine, resulting in increased inhibition, possibly via intercalated GABAerg cells, of projections from amygdala, affecting structures critically involved in depersonalization. I speculate that, in depersonalization disorder, the increased glutamate activity in prefrontal cortex is due to intrinsic imbalance, resulting in long-term potentiation, at the postsynaptic glutamate receptors on the GABAerg interneurons while the same receptor abnormality at the synapses on the intercalated GABAerg cells of the amygdala result in long-term depression in the case of either normal or high glutamate release

Clinical aspects on central venous cannulation

Central venous catheters are mainly being used for reliable infusion of fluids and potentially irritant drugs, for haemodialysis, and for assessment of right atrial or central venous pressure (RAP/CVP). Current guidelines state that central venous catheterization should be followed-up by immediate anterior-posterior chest X-ray to confirm appropriate positioning and to detect iatrogenic pneumothorax. However, the appropriate position is still questioned, and pneumothorax requiring therapeutic intervention may be detectable from clinical signs. A rare but serious complication of central venous cannulation is inadvertent arterial catheterization. Traditional pull and press techniques are associated with considerable risks when applied in noncompressible areas or when large bore catheters have been used. Repair of intrathoracic arteries may require extensive surgical or sophisticated endovascular approaches. The RAP/CVP have been reported to correlate with central venous return of blood and with peripheral venous pressure (PVP). Cuff-occluded rate of rise of peripheral venous pressure (CORRP), reflecting changes in PVP during proximal venous occlusion, has been proposed to predict hyper- or hypovolemia in dogs. In Study I patients with central venous cannulations were recorded prospectively. Individual radiographic records of corresponding routine control X-ray procedures were evaluated retrospectively. There were few complications from malpositioned catheter tips associated with short-term use. In Study II echocardiographic, and central and peripheral venous pressure measurements were made in patients with renal failure before and after haemodialysis. The changes in CORRP were found to correlate linearly with the volumes of fluid removed, whereas changes in RAP/CVP and PVP correlated with each other. In Study III inadvertent arterial catheterization after failed central venous cannulation was retrospectively found to be associated with obesity, emergency puncture, severe hypovolemia or lack of ultrasonic guidance, and to be successfully managed by endovascular therpeutic techniques. In Study IV records of routine control x-ray procedures after central venous catheterization were evaluated retrospectively, together with study protocol and medical charts. All iatrogenic pneumothoraces requiring therapeutic intervention were associated with clinical signs of respiratory distress or hypoxia. In conclusion, the results of this thesis indicate that routine post-procedural X-ray may be replaced by optional X-ray in selected patients, that CORRP (but not RAP/CVP) may predict changes in fluid balance, and that endovascular management is a feasible and safe therapeutic option in inadvertent arterial catheterization

Inadvertent arterial catheterization complicating femoral venous access for haemodialysis

Objective. Large-bore catheters for temporary haemodialysis are often placed via the internal jugular or femoral vein, guided by external landmarks or ultrasound techniques. Inadvertent femoral artery catheterization may occur during attempted placement of the dialysis catheter in the femoral vein. Material and methods. This investigation was carried out in Skane University Hospital, Malmo, Sweden. Between 2008 and 2011, patients referred for consultation by a vascular specialist owing to inadvertent arterial catheterization after attempted placement of a dialysis catheter in the femoral vein were noted in a logbook and patients with iatrogenic arterial injuries undergoing vascular repair at Malmo-Lund Hospitals were identified through the Swedish vascular registry (Swedvasc). Results. The five included patients had a dialysis catheter (11-13.5 Fr) inserted, without ultrasound guidance, into the femoral artery. One patient suffered from circulatory shock. Two cases were managed with external compression, while three cases required surgical repair. Two patients had postoperative wound infection in the groin. Conclusions. Femoral dialysis catheters should be inserted using ultrasound guidance. Large-bore catheters suspected of being in an inadvertent arterial position should be fixed securely before further diagnostic or interventional considerations. A management algorithm for inadvertently placed catheters in the femoral artery is proposed

Hypocapnia in women with fibromyalgia

Objectives: The purpose of this study was to investigate whether people with fibromyalgia (FM) have dysfunctional breathing by examining acid-base balance and comparing it with healthy controls. Methods: Thirty-six women diagnosed with FM and 36 healthy controls matched for age and gender participated in this cross-sectional study. To evaluate acid-base balance, arterial blood was sampled from the radial artery. Carbon dioxide, oxygen, bicarbonate, base excess, pH and lactate were analysed for between-group differences. Blood gas analyses were performed stepwise on each individual to detect acid-base disturbance, which was categorized as primary respiratory and possible compensation indicating chronicity. A three-step approach was employed to evaluate pH, carbon dioxide and bicarbonate in this order. Results: Women with FM had significantly lower carbon dioxide pressure (p = 0.013) and higher lactate (p = 0.038) compared to healthy controls at the group level. There were no significant differences in oxygen pressure, bicarbonate, pH and base excess. Employing a three-step acid-base analysis, 11 individuals in the FM group had a possible renally compensated mild chronic hyperventilation, compared to only 4 among the healthy controls (p = 0.042). Conclusions: In this study, we could identify a subgroup of individuals with FM who may be characterized as mild chronic hyperventilators. The results might point to a plausible dysfunctional breathing in some women with FM

Morning conferences for anaesthesiologists - to be or not to be?

BACKGROUND: The main objectives of this study were to clarify the contents of and attitudes to morning conferences for physicians at Swedish departments of anaesthesiology and intensive care medicine. METHODS: A prospective cross-sectional three-part study was carried out. Heads of departments responded to a national survey on the structure and content of morning conferences. A questionnaire on attitudes to and general contents of morning conferences was filled out by anaesthesiologists in the Scania region in southern Sweden. Furthermore, telephone interviews were made with anaesthesiologists on primary night call in the Scania region to obtain information on whether their needs to report had been met and on how the conferences had actually been carried out and attended by the physicians. RESULTS: Information was obtained from 52 departmental heads (80%), 113 anaesthesiologists (53%), and 83 physicians on primary call (92%). Issues most frequently brought up were reports from physicians on night call, discussions of clinical matters, issues of staffing, and organizational matters. Daily morning conferences were strongly favoured for intercollegial solidarity and contacts, and were mainly and regularly used for reports from physicians on night call. At 95% of them, physicians on night call considered themselves to have been allowed to report what they wanted or needed to. CONCLUSIONS: Daily morning conferences enable regular exchange of information and professional experience, and are considered by Swedish anaesthesiologists to be most valuable for intercollegial solidarity and contacts. Before changes are being made in frequency or duration of morning conferences, their actual structure and content should be carefully evaluated and critically challenged to fit specific needs of that individual department

Endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization.

ABSTRACT Objectives: This study was designed to assess endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization. Methods: Patients referred for endovascular management of central venous occlusion during a 42-month period were identified from a regional endovascular database, providing prospective information on techniques and clinical outcome. Corresponding patient records, angiograms, and radiographic reports were analyzed retrospectively. Results: Sixteen patients aged 48 years (range 0.5-76), including 11 females, were included. All patients but 1 had had multiple central venous catheters with a median total indwelling time of 37 months. Eleven patients cannulated for hemodialysis had had significantly fewer individual catheters inserted compared with 5 patients cannulated for nutritional support (mean 3.6 vs. 10.2, p<0.001) before endovascular intervention. Preoperative imaging by magnetic resonance tomography (MRT) in 8 patients, computed tomography (CT) venography in 3, conventional angiography in 6, and/or ultrasonography in 8, verified 15 brachiocephalic, 13 internal jugular, 3 superior caval, and/or 3 subclavian venous occlusions. Patients were subjected to recanalization (n=2), recanalization and percutaneous transluminal angioplasty (n=5), or stenting for vena cava superior syndrome (n=1) prior to catheter insertion. The remaining 8 patients were cannulated by avoiding the occluded route. Conclusions: Central venous occlusion occurs particularly in patients under hemodialysis and with a history of multiple central venous catheterizations with large-diameter catheters and/or long total indwelling time periods. Patients with central venous occlusion verified by CT or MRT venography and need for central venous access should be referred for endovascular intervention

Fatal arterial complications following ultrasound-guided attempt of internal jugular vein catheterization

Puncture of the posterior venous wall during ultrasound-guided internal jugular vein cannulation seems to be common, making underlying artery at risk of injury. Two cases of injury through the posterior wall of the internal jugular vein and an injury to the underlying artery are reported. In case number 1, a small injury of the carotid arterial wall resulted in a retrograde dissection of the common carotid artery and ascending part of the aorta, causing a fatal cardiac tamponade-a sequence of events never previously described. In case number 2, an unexpected injury to the thyrocervical trunk in a severely thrombocytopenic patient caused an extensive hematoma that compromised the upper airway, eventually leading to a fatal outcome. These two reported fatal arterial complications during ultrasound-guided cannulation of the internal jugular vein add to other publications of complications after central vein catheterization. It is important to increase awareness of these avoidable serious complications

Early surgical results after pneumonectomy for non-small cell lung cancer are not affected by preoperative radiotherapy and chemotherapy.

BACKGROUND: Higher operative risks after pneumonectomy for non-small cell lung cancer (NSCLC) have been reported after neoadjuvant chemotherapy or radiotherapy, or both. Patients who underwent pneumonectomy for NSCLC were evaluated for effect of neoadjuvant treatment on mortality and morbidity, especially bronchopleural fistula. METHODS: Between 1996 and 2003, 130 consecutive patients underwent pneumonectomy: 35 received preoperative radiotherapy and chemotherapy (the neoadjuvant group), and 95 patients did not (the first-surgery group). Operative mortality and postoperative complications were compared between the groups. RESULTS: Minor postoperative complications were comparable in both groups (p > 0.10). Five patients in the neoadjuvant group and 10 in the first-surgery group had serious complications (p = 0.55). Eight had bronchopleural fistulas (7 right and 1 left, p 0.2). CONCLUSIONS: Pneumonectomy is a safe procedure with low operative mortality. Postoperative morbidity is significant, especially bronchopleural fistulas after right-sided pneumonectomy (11%). However, neither operative mortality nor morbidity appears to be directly associated with preoperative radiotherapy or chemotherapy

Internal jugular dimensions and common carotid overlapping assessed in a cross-sectional study by ultrasonography at three neck levels in healthy volunteers

Background: Cannulation of the internal jugular vein may be associated with inadvertent puncture of the common carotid artery. Systematic use of ultrasound guidance has improved clinical success rates and reduced complications, but better knowledge of topographic relationships of the internal jugular vein and common carotid artery is desirable. This preclinical study was designed to determine by ultrasound technique relative topographic characteristics in humans of the internal jugular veins and common carotid arteries at different levels on both sides of the neck. Methods: One hundred and twenty healthy volunteers were examined bilaterally by ultrasound at three neck levels with and without contralateral rotation of the head. Twelve digital pictures were recorded and used to determine venous diameters and extents of arteriovenous overlapping in each subject. Results: Venous dimensions and arteriovenous overlapping were larger on the right side (p = 0.008) regardless of head rotation at all levels. There was more arteriovenous overlapping with than without rotation at right high- and mid-cervical levels (p<0.001). The only difference between right mid- and low-cervical levels was less arteriovenous overlapping at mid-cervical level without rotation (p = 0.017). The smallest venous dimensions and extent of arteriovenous overlapping were recorded at high-cervical level. Conclusions: Despite similar venous dimensions, less arteriovenous overlapping regardless of head rotation at mid-cervical level, together with the pleural proximity at low-cervical level, propose the internal jugular vein to be anatomically (other factors disregarded) favorable for vascular access on the right side, at mid-cervical level, close to the angle between the sternocleidomastoid muscle bellies, and with minimal rotation of the head